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Talipes Equinovarus

Talipes Equinovarus

* Talipes: derived from talus ( L = ankle bone ) and pes ( L = foot ).

* Equinovarus: one of the several different deformities of talipes and means that the entire hindfoot is in varus and the mid & forefoot are adducted and supinated.

* Others: Talipes calcaneus & Talipes valgus.

Incidence

* 1-2 every 1000 live births.

* Boys : Girls → 2 : 1 .

* Sporadic but may be autosomaldominant trait.

* Bilateral in 50% of patients or in one third of cases.

Causes / Mechanisms

1- Genetic defect : primary germ plasm defect in the talus causes continued planter flexion and inversion of this bone and soft tissue changes.

2- Form of arrested development.

3- Neuromuscular disorder : primary soft tissue abnormalities within neuromuscular units cause secondary bony changes , e.g : neural tube defect.

What part of the foot is affected?

Clubfoot primarily affects three bones: calcaneus, talus and navicular.

The deformity can affect the growth of the entire foot to some degree so other bones may be involved as well.

Pathological Anatomy

①Talus :

- Neck : downwards , deviated medially.

- Body : rotated slightly outwards in relation to calcaneus and ankle mortise.

②Calcaneus :

- Posterior part is held close to fibula by a tight calcaneo-fibular ligament and tilted into equinus and medially rotated beneath the ankle.

③Navicular & the entire forefoot :

- Shifted medially and rotated into supination.

④Metatarsals : adducted & deviated at tarsometatarsal joints.

Clinical Picture

1- Foot is turned & twisted inwards , so the sole faces posteromedially with high medial arch ( cavus ) & smaller than the other normal foot.

2- Ankle is in equinus.

3- Forefoot is adducted & supinated.

4- Skin & soft tissues of the calf &medial side of the foot are short & underdeveloped.

5- The heel is small & high.

6- Deep creases appear posteriorly & medially.

Examination

* In infants :

examine associated disorders as congenital hip dislocation & spina bifida.

* 3 Basic components of club foot :

equinus , varus , adduction , & may be cavus.

Roentgenographic Evaluation

* Before , during & after treatment.

* To assess progress after treatment.

* 3 views:

- AP with foot 30° planter flexion & tube angled 30°.

- Stress dorsiflexion lateral view of both heels.

- Lateral standing view : in older children.

* Important angels :

1- Talocalcaneal angle.

2- Talo-1st metatarsal angle.

AP film

- Line is drawn through the long axis of talus parallel to its medial border & through the calcaneus parallel to its lateral border , normally cross at angle 20°- 40° “ Kite’s angle

“, in club foot , the two lines may be parallel.

Lateral Film

* Foot is forced dorsiflexion.

* Line is drawn through the mid-longitudinal axis of talus & lower border of calcaneus , normally the angle is 40°.

* If the angle is less than 20° >>> club foot.

* Angles normally changes with age.

* Club foot can’t be dorsiflexed , but if so , it will be broken at the midtarsal level producing “Rocker – Bottom deformity”.

Treatment

- Aim : to produce & maintain a plantigrade , replase may occur in neuromuscular disorders babies.

① Non-operative : the initial treatment.

- Repeated manipulation & adhesive strapping.

- Weekly serial manipulation & light plaster cast during the first 6 weeks of life followed by manipulation & casting every the other week untill the foot clinically & roentgenohraphiccorrected.

* With experience , predict which feet will respond to non-surgical treatment.

* The more the rigid the initial deformity , more likely surgical treatment.

* The order of correction :

1- Correction of forefoot adduction : rotational alignment with hindfoot , by ↑ supination deformity.

2- Correction of hindfoot & forefoot for varus & supination by keeping fulcrum on the lateral side of head of talus.

3- Correction of hindfoot equinus by bringing the heel down & dorsiflexing the ankle & percutaneous tendo Achillislengthening.

* The aim of the order is to prevent “Rocker Bottom Deformity”by dorsiflexing the foot from the hindfoot rather than midfoot , but if occurs, forefoot placed back in planter flexion , casting & surgery is important here.

* Casting by Kite , modified by Lovell & Hancock.

* Manipulation & casting success rate is 15-80%.

* Resistant cases declare after 8-12 weeks of serial manipulation & strapping , so early surgery or continued conservative treatment is indicated.

* Delaying surgery untill child walking >>> surgery is easier & maintenance of the correction. It is suitable for severe ,

rigid deformities.

* Less severe cases >>> operation at 6 months.

Operative Treatment ②

Operative Treatment

* Indication :

1- No response to conservative treatment often in children with significant rigid deformity.

2- Deformity has recurred.

3- The forefoot has been corrected by conservative treatment but hindfoot remains fixed in both varus & equinus.

* Surgical treatment is according to the age of child & deformity to be corrected.

* Objectives :

1- Complete release of joint tethers.

2- Lengthening of tendons.

Incisions

1- Posteromedial incision >>> Turco.

2- Posterior curved transverse , extended anteriorly on both sides medial & lateral >>>Cincinatti – Crawford.

3- Posterolateral with separate curved medial incision >>> Caroll.

* To correct equinus :

1- Achillis tendon & tibialis posterior tendon are lengthened through Z-divisions.

2- Posterior capsules of ankle & subtalar joints are divided.

* To correct cavus :

1- Release contractures around talonavicular & calcanocuboid joints.

2- Origin of intrinsic muscles & planter fascia from calcaneum are divided.

* The foot , in its corrected position , is immobilized in a plaster cast.

* Kirshner wires >>> across talonavicular & subtalar joint.

* Wires & cast are removed at 6-8 weeks.

* After immobilization , hobble boots “Dennis

Browne “.

* Stretching exercises are continued.

Dennis Browne “

DAFOs for Clubfoot:designed for soft, comfortable repositioning of

clubfoot or maintaining post-surgical positions

Late or relapsed club foot

* Late >>> comes with secondary bony changes.

* Relapsed >>> scarring of previous surgery.

*Youngs ( 4-7 ) years >>> calcaneo-cuboid fusion or cuboid enucleation ( Dilwyn Evans ).

* Calcaneal osteotomies >>> for varus.

* Tendon transfer.

* Circular external fixator ( Ilizarov method ) >>> gradual correction.

Metatarsus adductus

* Varies from slightly curved forefoot to mild club foot.* Management :

- 90% improve spontaneously.- corrective casts followed by straight last shoes.- Extensive capsulectomy of tarsometatarsal

joints. No splintage to avoid early degenerative arthritis.

- Dilwyn Evans procedure + Basal metatarsal osteotomy.

Talipes Calcaneovalgus